Can rifaximin tablets be crushed?

Can Rifaximin Tablets Be Crushed?

Yes, rifaximin tablets can be crushed when necessary for patients unable to swallow whole tablets, though this should be done with appropriate precautions and only when alternative formulations are unavailable.

Evidence Supporting Crushing

Stability Data

• Rifaximin maintains excellent stability when crushed and prepared as an extemporaneous suspension, with at least 99% of the initial drug concentration remaining stable for 60 days when mixed with appropriate suspending vehicles 1
• When crushed tablets are suspended in 1:1 mixtures of Ora-Plus with either Ora-Sweet or Ora-Sweet SF, there are no detectable changes in color, odor, taste, pH, or visible microbial growth 1

Clinical Context

• Rifaximin is a non-absorbable antibiotic (<0.4% systemic absorption) that maintains high intestinal concentrations (>8000 μg/g in feces) regardless of formulation manipulation 2
• The drug's mechanism of action depends on local gastrointestinal activity rather than systemic absorption, making it less susceptible to pharmacokinetic alterations from crushing 2

Administration Guidelines When Crushing

Preparation Method

• Thoroughly grind tablets in a glass mortar to create a fine powder 1
• Immediately suspend the crushed powder in an appropriate vehicle (water or suspending agent) 1
• Administer promptly after preparation to ensure full dose delivery 3

Safety Precautions

• The person crushing tablets should use appropriate protective equipment to avoid exposure to drug particles, as this is a general concern with tablet manipulation 4
• Flush feeding tubes with at least 30 mL of water before and after administration to prevent obstruction 5
• Use gastric tubes rather than jejunal tubes for administration to ensure proper absorption 5

Important Caveats

When Crushing Should Be Avoided

• Do not crush if an oral suspension formulation can be obtained from the pharmacy, as this is the preferred alternative 1
• Crushing should only be done as a last resort when no suitable alternative exists 4, 6

Limitations in Severe Hepatic Encephalopathy

• The maximum rifaximin dose of 1,200 mg/day may limit its use in severe hepatic encephalopathy (West-Haven grade 3 or higher) specifically because of the need for oral administration 7
• This limitation relates to the patient's ability to take medications orally rather than any inherent problem with crushing the tablets 7

Clinical Monitoring

• Monitor for therapeutic efficacy after administering crushed rifaximin, particularly in patients with hepatic encephalopathy or travelers' diarrhea 7
• Rifaximin has an excellent safety profile with adverse reactions comparable to placebo, which is maintained even when tablets are manipulated 2